maryland preferred drug list 141 pdl and some... · note: brand names listed in parentheses are...

*Changes from the previous PDL are highlighted in yellow

Maryland's Preferred Drug List—Effective January 1, 2014 Medicaid's Preferred Drug List (PDL), encompassing over 1700 drugs, covers most of the generic versions of preferred multisource brand drugs without any type of prior authorization. If the prescription for a brand name drug is to be dispensed as written, the prescriber must complete and

submit a Medwatch form (http://mmcp.dhmh.maryland.gov/pap/docs/Maryland%20Medwatch%20Form.pdf). The State's clinical pharmacy

team will review the Medwatch form and notify the prescriber whether the request for the brand name drug was approved or denied. The State will forward the Medwatch form to the FDA. The first two pages of this PDL Advisory is to alert you to changes* in the exceptions to this rule that will become effective January 1, 2014. Brand name Cymbalta®, Focalin® Tablets, Focalin® XR Capsules, Gabitril®, Ritalin LA® Capsules, Tegretol® Suspension, Trileptal® Suspension and Tobi® Inhalation Solution will be preferred over their generic equivalents. Also.both Nasocort AQ and it’s generic (triamcinolone nasal) are now non-preferred.

Not All Generics are Preferred In order for the State to enhance the benefit of the PDL, in some instances the multisource brand name drug is Preferred over its generic equivalents, because the branded drug is less costly than its generic counterpart. This happens most often in cases of newly released generics. When manufacturer rebates are taken into consideration, the brand name drug has a lower net cost to the State. When the brand name drug is Preferred, no Medwatch nor authorization is needed1. Enter a DAW code of 6 on the claim to have it correctly priced. If any problems are encountered during the on-line claim adjudication of Preferred Brands, contact the Xerox 24-hour Help Desk at 800-932-3918 for additional system overrides related to the use of the correct DAW code (for example, if the member has primary insurance).

1 Unless the Program has established clinical criteria for the drug

No. 141

December 19, 2013

In an effort to give timely notice to the pharmacy community concerning important pharmacy topics, the Department of Health and Mental Hygiene’s (DHMH) Maryland Medicaid Pharmacy Program (MMPP) has developed the Maryland Medicaid Pharmacy Program Advisory. To expedite information timely to the pharmacy and prescriber communities, an email network has been established which incorporates the email lists of the Maryland Pharmacists Association, EPIC, CARE, Long Term Care Consultants, headquarters of all chain drugstores and prescriber associations and organizations. It is our hope that the information is disseminated to all interested parties. If you have not received this email through any of the previously noted parties or via DHMH, please contact the MMPP representative at 410-767-1455.

http://mmcp.dhmh.maryland.gov/pap/docs/Maryland%20Medwatch%20Form.pdf

Please maintain this for a reference together with any updates that follow. This information is available at http://www.epocrates.com/ on your desktop computer or PDA/Smartphone. Epocrates is updated weekly. The generic non-preferred exceptions are as follows: Non-Preferred Generics Preferred Brands adapalene Differin amphetamine salt combo ER Adderall XR azelastine Astelin brimonidine P 0.15% Alphagan P 0.15% budesonide respules Pulmicort respules carbamazepine XR and ER caps Carbatrol ER capsules carbamazepine suspension Tegretol suspension clonidine patches Catapres TTS patches cyclosporine Sandimmune dexmethylphenidate tablets Focalin tablets dexmethylphenidate XR caps Focalin XR capsules dextroamphetamine Dexedrine spansules diazepam rectal Diastat diltiazem ER Cardizem LA divalproex sprinkles Depakote Sprinkles dronabinol Marinol duloxetine delayed release caps Cymbalta enoxaparin Lovenox fenofibrate Tricor lidocaine 5% patch Lidoderm 5% Patch methylphenidate ER-LA caps Ritalin LA capsules methylphenidate CD caps Metadate CD methylphenidate liquid Methylin Oral Solution metoprolol succinate XL Toprol XL morphine sulfate ER Kadian oxcarbazepine suspension Trileptal suspension tiagabine Gabitril tobramycin inhalation soln Tobi Inhalation Solution tobramycin/dexamethasone Tobradex tranylcypromine Parnate vancomycin oral Vancocin In the following instances, both the multisource brand and the generic are preferred: Preferred generics Brand also Preferred (no MedWatch form required) metipranolol Optipranolol metronidazole Metrogel-vaginal

http://www.epocrates.com/

MARYLAND PREFERRED DRUG LIST

Effective Date 1/1/14

Key: All lowercase letters = generic product. Leading capital letter = brand name product. of 18

Only drugs that are part of the listed therapeutic categories are affected by the PDL. Therapeutic categories not listed here are

not part of the PDL and will continue to be covered as they always have for Maryland Medicaid patients.

Note: Brand names listed in parentheses are only listed as a reference. For most multi-source products, the generic product(s) are

usually preferred and branded innovator product(s) are non-preferred. If a generic product is non-preferred, the corresponding

brand product is also non-preferred except where specifically noted as “(generic only)”. PDL products that are new to market

require prior authorization until they are reviewed.

Changes in the Preferred Drug List are highlighted in yellow.

Analgesics

Drug Class Preferred Requires Prior Authorization

Analgesics, Narcotics (Long Acting) fentanyl patch (Duragesic)

methadone (Dolophine)

morphine sulfate SR (MS Contin)

Kadian (Brand only)

morphine sulfate ER (Kadian) (generic only)

oxymorphone ER (Opana ER)

tramadol ER (Ultram ER, Ryzolt)

Avinza

Butrans

Conzip

Exalgo

Nucynta ER

Oxycontin

Analgesics, Narcotics (Short Acting)

*Clinical Criteria applies to fentanyl buccal tablets (Fentora), fentanyl buccal lozenges (Actiq, generic), Abstral (fentanyl sublingual tablets) and Onsolis (fentanyl buccal film). To view criteria, please refer to http://www.mdrxprograms.com/docs/medicaid/MD_FENTANYAL%20BUCCAL%20Rev%20Feb08.pdf.

apap w/codeine (Tylenol w/Codeine)

butalbital/apap/codeine/caffeine

butalbital/aspirin/codeine/caffeine

codeine tablets

dihydrocodeine/aspirin/caff (Synalgos DC)

hydrocodone/apap (Vicodin)

hydrocodone/ibuprofen (Vicoprofen)

hydromorphone tablets (Dilaudid)

morphine sulfate tablets

oxycodone

oxycodone/apap (Percocet)

oxycodone/aspirin (Percodan)

pentazocine/apap (Talacen)

pentazocine/naloxone (Talwin NX)

tramadol (Ultram)

tramadol/apap (Ultracet)

butorphanol nasal spray

carisoprodol/codeine/asa

codeine solution

dihydrocodeine/apap/caffeine

fentanyl transmucosal and buccal (Actiq and Fentora)*

hydromorphone suppositories and solution

levorphanol

meperidine (Demerol)

morphine suppositories

oxycodone/ibuprofen (Combunox)

oxymorphone (Opana)

Abstral*

Ibudone

Nucynta

Onsolis *

Oxecta

Primlev

Rybix ODT

Subsys

Zamicet

Zolvit

Anti-Hyperuricemics allopurinol (Zyloprim)

probenecid

probenecid/colchicine

Colcrys

Uloric

http://www.mdrxprograms.com/docs/medicaid/MD_FENTANYAL%20BUCCAL%20Rev%20Feb08.pdf






Analgesics


Anti-Migraine Agents sumatriptan (Imitrex)

Relpax

naratriptan (Amerge)

rizatriptan, rizatriptan ODT (Maxalt, Maxalt MLT)

zolmitriptan, zolmitriptan ODT (Zomig, Zomig ZMT)

Axert

Cambia

Frova

Sumavel Dosepro

Treximet

Zomig Nasal

Neuropathic Pain

*Clinical criteria apply to Cymbalta. To view criteria, please refer to http://mmcp.dhmh.maryland.gov/pap/SitePages/Clinical%20Criteria.aspx.

capsaicin OTC

gabapentin capsules (Neurontin)

Cymbalta* (Brand only)

Lidoderm (Brand only)

Lyrica capsules

duloxetine (Cymbalta) (generic only)

gabapentin tablets and solution (Neurontin)

lidocaine patch (generic only)

Gralise

Horizant

Lyrica solution

Qutenza

Savella

Zostrix OTC

Nonsteroidal Anti-Inflammatories/COX II

Inhibitors (NSAIDS, Cyclooxygenase

Inhibitors – Type II)

diclofenac, diclofenac XL (Cataflam, Voltaren XR)

diflunisal (Dolobid)

etodolac, etodolac XL (Lodine, Lodine XL)

fenoprofen

flurbiprofen (Ansaid)

ibuprofen Rx and OTC (Motrin)

indomethacin, indomethacin SR (Indocin, Indocin SR)

ketoprofen (Orudis, Oruvail)

ketorolac (Toradol)

meclofenamate (Meclomen)

meloxicam tablets (Mobic)

nabumetone (Relafen)

naproxen Rx and OTC (Aleve, Naprosyn)

oxaprozin (Daypro)

piroxicam (Feldene)

sulindac (Clinoril)

Voltaren gel

diclofenac/misoprostol (Arthrotec)

mefenamic acid (Ponstel)

tolmetin, tolmetin DS (Tolectin, Tolectin DS)

Celebrex

Duexis

Flector

Indocin suppositories and suspension

Mobic suspension

Pennsaid

Sprix Nasal

Vimovo

Zipsor

Skeletal Muscle Relaxants baclofen (Lioresal)

carisoprodol 350mg (Soma)

chlorzoxazone (Parafon)

cyclobenzaprine (Flexeril)

dantrolene (Dantrium)

methocarbamol (Robaxin)

orphenadrine (Norflex)

tizanidine tablets (Zanaflex)

carisoprodol 250mg (Soma)

carisoprodol compound (Soma Compound)

metaxalone (Skelaxin)

orphenadrine compound (Norflex Forte)

tizanidine capsules (Zanaflex)

Amrix

Fexmid

Lorzone

http://mmcp.dhmh.maryland.gov/pap/SitePages/Clinical%20Criteria.aspx






Anti-Infectives


Antibiotics, GI metronidazole tablets (Flagyl)

neomycin

Alinia

Vancocin (Brand Only)

metronidazole capsules (Flagyl capsules)

tinidazole (Tindamax)

vancomycin capsules (Vancocin) (generic only)

Dificid

Flagyl ER

Xifaxan

Antibiotics, Inhaled Tobi nebules (Brand Only) tobramycin nebules (Tobi) (generic only)

Cayston

Tobi Podhaler

Antibiotics, Vaginal clindamycin (Clindamax)

metronidazole vaginal (Metro-Gel) (Brand and generic)

Cleocin ovules

Cleocin cream

Vandazole

Antifungals, Oral (Antifungal Agents, Antifungal Antibiotics)

fluconazole (Diflucan)

griseofulvin ultra tablets (Gris Peg)

ketoconazole (Nizoral)

nystatin

terbinafine (Lamisil)

clotrimazole troche (Mycelex)

flucytosine (Ancobon)

griseofulvin tablets and suspension (Fulvicin, GriFulvin V)

itraconazole (Sporanox)

voriconazole (Vfend)

Lamisil granules

Noxafil suspension

Onmel

Terbinex

Antifungals, Topical (Topical Antifungals)

clotrimazole Rx and OTC

clotrimazole/betamethasone (Lotrisone)

econazole (Spectazole)

ketoconazole cream and shampoo (Nizoral)

miconazole OTC

nystatin

nystatin/triamcinolone (Mycolog)

terbinafine OTC

tolnaftate OTC

tolnaftate aero powder

butenafine OTC (Mentax)

ciclopirox (Loprox, Loprox Shampoo, Penlac)

ketoconazole foam

Bensal HP

CNL-8

Ertaczo

Exelderm

Extina

Oxistat

Pediaderm AF

Pediprox-4

Vusion

Antiparasitics, Topical permethrin Rx and OTC (Elimite, Acticin)

piperonyl/pyrethrins OTC

piperonyl/pyrethrins/permethrin OTC

Eurax cream

lindane

malathion (Ovide)

spinosad (Natroba)

Eurax lotion

Sklice

Ulesfia




Anti-Infectives


Antivirals, Oral (Antivirals, General) acyclovir (Zovirax)

amantadine (Symmetrel)

rimantadine (Flumadine)

valacyclovir (Valtrex)

famciclovir (Famvir)

Relenza

Tamiflu

Antivirals, Topical acyclovir ointment (Zovirax Ointment)

Abreva OTC

Denavir

Xerese

Zovirax Cream

Cephalosporin and Related Agents (Cephalosporins, Second and Third Generation, Penicillins)

amoxicillin/clavulanate (Augmentin, Augmentin ES)

cefaclor, cefaclor ER (Ceclor, Ceclor CD)

cefadroxil (Duricef)

cefdinir (Omnicef)

cefprozil (Cefzil)

cefuroxime (Ceftin)

cephalexin (Keflex)

Suprax tablets, capsules and suspension

amoxicillin/clav ER (Augmentin XR)

cefditoren (Spectracef)

cefpodoxime (Vantin)

ceftibuten (Cedax)

Ceftin tablets and suspension

Suprax chewables

Fluoroquinolones (Quinolones) ciprofloxacin (Cipro)

levofloxacin (Levaquin)

ciprofloxacin ER (Cipro XR)

ofloxacin (Floxin)

Avelox

Cipro suspension

Factive

Noroxin

Hepatitis C Agents (Hepatitis C Treatment Agents, Immunomodulators)

ribavirin (Copegus, Rebetol)

Incivek

Pegasys

Pegasys Proclick

Peg-Intron

Peg-Intron Redipen

Victrelis

Infergen

Rebetol solution

Ribapak

Ribasphere

Macrolides/Ketolides azithromycin (Zithromax)

erythromycin base

E.E.S.

Ery-Tab

EryPed

Erythrocin

clarithromycin (Biaxin)

clarithromycin ER (Biaxin XL)

Ketek

PCE

Zmax

Tetracyclines doxycycline hyclate (Vibramycin)

doxycycline monohydrate (Monodox)

minocycline (Minocin)

tetracycline (Sumycin)

demeclocycline (Declomycin)

doxycycline hyclate DR (Doryx)

doxycycline monohydrate solution (Vibramycin)

minocycline ER

Adoxa

Morgidox

Oracea

Solodyn




Anti-Infectives


Topical Antibiotics bacitracin OTC

bacitracin/polymyxin OTC

gentamicin

mupirocin ointment (Bactroban Ointment)

triple antibiotic OTC

mupirocin cream (Bactroban Cream)

Altabax

Centany

Cardiovascular


Angiotensin Modulator Combinations

amlodipine/benazepril (Lotrel)

Azor/Tribenzor

Exforge/Exforge HCT

Tarka

Tekamlo/Amturnide

Twynsta

Angiotensin Modulators benazepril, benazepril HCTZ (Lotensin, Lotensin HCT)

captopril, captopril HCTZ (Capoten, Capozide)

enalapril, enalapril HCTZ (Vasotec, Vaseretic)

fosinopril, fosinopril HCTZ (Monopril, Monopril HCT)

irbesartan, irbesartan HCTZ (Avapro, Avalide)

lisinopril, lisinopril HCTZ (Prinivil, Zestril, Prinzide, Zestoretic)

losartan, losartan HCTZ (Cozaar, Hyzaar)

quinapril, quinapril HCTZ (Accupril, Accuretic)

ramipril (Altace)

valsartan HCTZ (Diovan HCT)

Diovan

candesartan, candesartan HCTZ (Atacand, Atacand HCT)

eprosartan (Teveten)

moexipril, moexipril HCTZ (Univasc, Uniretic)

perindopril (Aceon)

trandolapril (Mavik)

Benicar, Benicar HCT

Edarbi, Edarbyclor

Micardis, Micardis HCT

Tekturna/Tekturna HCT

Teveten HCT

Anticoagulants warfarin (Coumadin)

Fragmin

Lovenox (Brand only)

enoxaparin (generic only)

fondaparinux (Arixtra)

Eliquis

Pradaxa

Xarelto

Antihypertensives, Sympatholytics clonidine oral (Catapres)

guanfacine (Tenex)

methyldopa (Aldomet)

methyldopa/HCTZ (Aldoril)

Catapres-TTS (Brand only)

clonidine transdermal (generic only)

reserpine

Clorpres

Beta Blockers (Alpha/Beta-Adrenergic Blocking Agents, Beta-Adrenergic Blocking Agents)

atenolol (Tenormin), atenolol/chlorthalidone (Tenoretic)

bisoprolol/HCTZ (Ziac)

carvedilol (Coreg)

labetalol (Normodyne, Trandate)

metoprolol tartrate (Lopressor)

nadolol (Corgard)

pindolol (Visken)

propranolol (Inderal), propranolol/HCTZ (Inderide)

propranolol LA (Inderal LA)

sotalol, sotalol AF (Betapace, Betapace AF)

acebutolol (Sectral)

betaxolol (Kerlone)

bisoprolol (Zebeta)

metoprolol/HCTZ (Lopressor HCT)

metoprolol succinate XL (Toprol XL) (generic only)

nadolol/bendroflumethiazide (Corzide)

timolol (Blocadren)

Bystolic

Coreg CR

Dutoprol




Cardiovascular


Toprol XL (Brand only)

Innopran XL

Levatol

Calcium Channel Blocking Agents amlodipine (Norvasc)

diltiazem (Cardizem)

nicardipine (Cardene)

nifedipine SR (Adalat CC, Procardia XL)

verapamil (Calan)

verapamil ER tablets (Calan SR, Verelan)

Cardizem LA (Brand only)

diltiazem ER capsules (Cardizem CD, Tiazac)

felodipine (Plendil)

isradipine (Dynacirc)

nifedipine (Adalat, Procardia)

nimodipine (Nimotop)

nisoldipine (Sular)

verapamil ER capsules (Verelan PM)

Dynacirc CR

Matzim LA (generic only)

Nymalize

Lipotropics, Other (Lipotropics, Bile Salt Sequestrants)

cholestyramine (Questran, Light)

fenofibric acid (Trilipix)

niacin ER (Niaspan ER)

gemfibrozil (Lopid)

Niacor

Tricor (Brand only)

colestipol (Colestid)

fenofibrate (Antara, Lofibra)

fenofibrate nanocrystals (Tricor) (Generic only)

fenofibric acid (Fibricor)

Lipofen

Lovaza

Triglide

Welchol

Zetia

Lipotropics, Statins (Lipotropics) atorvastatin (Lipitor)

fluvastatin (Lescol

lovastatin (Mevacor)

pravastatin (Pravachol)

simvastatin (Zocor)

Lescol XL

Simcor

amlodipine/atorvastatin (Caduet)

Advicor

Altoprev

Crestor

Liptruzet

Livalo

Vytorin

Platelet Aggregation Inhibitors clopidogrel (Plavix)

dipyridamole (Persantine)

ticlopidine (Ticlid)

Aggrenox

Brilinta

Effient

Pulmonary Arterial Hypertension, Oral and Inhaled Agents

*Clinical Criteria applies to Adcirca and

Revatio. To view criteria, please refer to

http://mmcp.dhmh.maryland.gov/pap/d

ocs/PAH-Drugs-PA-form.pdf.

sildenafil* (Revatio)

Adcirca*

Letairis

Tracleer

Ventavis

Tyvaso

http://mmcp.dhmh.maryland.gov/pap/docs/PAH-Drugs-PA-form.pdf

http://mmcp.dhmh.maryland.gov/pap/docs/PAH-Drugs-PA-form.pdf




Central Nervous System The Mental Health Carve Out link is located at:http://www.mdmahealthchoicerx.com/healthchoice_docs/mmmh_form.pdf


Anticonvulsants carbamazepine (Tegretol)

clonazepam (Klonopin)

divalproex (Depakote, Depakote ER)

lamotrigine (Lamictal)

levetiracetam (Keppra)

oxcarbazepine tablets (Trileptal)

phenobarbital

phenytoin (Dilantin, Dilantin Infatabs)

primidone (Mysoline)

topiramate (Topamax)

valproic acid (Depakene)

zonisamide (Zonegran)

Carbatrol (Brand only)

Celontin

Depakote sprinkles (Brand only)

Diastat rectal (Brand only)

Gabitril (Brand only)

Peganone

Tegretol Suspension (Brand only)

Trileptal Suspension (Brand only)

carbamazepine ER caps (Carbatrol) (generic only)

carbamazepine suspension (Tegretol) (generic only)

carbamazepine XR (Tegretol XR)

clonazepam ODT (Klonopin ODT)

diazepam rectal (Diastat) (generic only)

divalproex sprinkles (Depakote sprinkles) (generic only)

ethosuximide (Zarontin)

felbamate (Felbatol)

lamotrigine ER (Lamictal XR)

levetiracetam ER (Keppra XR)

oxcarbazepine suspension (Trileptal Suspension) (generic only)

tiagabine (Gabitril) (generic only)

topiramate sprinkles (Topamax Sprinkles)

Banzel

Equetro

Lamictal ODT

Onfi

Phenytek

Potiga

Sabril

Stavzor

Trokendi XR

Vimpat

Antidepressants, Other (Alpha-2 Receptor Antagonist Antidepressants, Serotonin-2 Antagonist/Reuptake Inhibitors, Serotonin-Norepinephrine Reuptake-Inhib, Norepinephrine and Dopamine Reuptake Inhib)

bupropion, bupropion SR, buproprion XL (Wellbutrin, Wellbutrin SR, Wellbutrin XL)

mirtazapine, mirtazapine soltab (Remeron, Remeron Soltab)

phenelzine (Nardil)

trazodone (Desyrel)

venlafaxine (Effexor)

venlafaxine ER capsules (Effexor XR)

Marplan

Parnate (Brand only)

nefazodone (Serzone)

tranylcypromine (generic only)

venlafaxine ER tablets

Aplenzin

Emsam

Forfivo XL

Oleptro ER

Pristiq

Viibryd

Antidepressants, Selective Serotonin Reuptake Inhibitors (SSRIs)

citalopram (Celexa)

escitalopram (Lexapro)

fluoxetine (all strengths except 60mg) (Prozac, Sarafem)

fluvoxamine (Luvox)

paroxetine (Paxil)

sertraline (Zoloft)

fluoxetine 60mg

fluoxetine weekly (Prozac weekly)

fluvoxamine ER (Luvox CR)

paroxetine CR (Paxil CR)

Brisdelle

Paxil suspension

Pexeva

http://www.mdmahealthchoicerx.com/healthchoice_docs/mmmh_form.pdf






Antipsychotics**

** Additional clinical edits may apply to

the Tier 2 products. An adequate trial of a

Tier 1 preferred drug is required prior to

use of any Tier 2 product. To view

criteria, please refer to

http://mmcp.dhmh.maryland.gov/pap/Sit

ePages/Clinical%20Criteria.aspx.

**All antipsychotics for patients 17 years

of age and under must be approved

through the peer review process through

the University of Maryland. To view

criteria, please refer to



1st Tier

chlorpromazine (Thorazine)

clozapine (Clozaril)

fluphenazine (Prolixin)

fluphenazine decanoate inj (Prolixin Inj.)

haloperidol (Haldol)

haloperidol decanoate inj (Haldol IM)

perphenazine (Trilafon)

perphenazine/amitriptyline (Triavil)

quetiapine (Seroquel)

risperidone (Risperdal)

thioridazine (Mellaril)

thiothixene (Navane)

trifluoperazine (Stelazine)

ziprasidone (Geodon)

Abilify (Age 17 and younger)

Abilify Maintena

Geodon IM

Invega Sustenna

Orap

Risperdal Consta

2nd Tier

olanzapine IM (Zyprexa IM)

olanzapine ODT (Zyprexa Zydis)

olanzapine (Zyprexa)

Abilify (Age 18 or older)

Latuda

clozapine ODT (Fazaclo)

olanzapine/fluoxetine (Symbyax)

Abilify IM

Fanapt

Invega

Saphris

Seroquel XR

Zyprexa Relprevv

Sedative Hypnotics

* Step therapy for Lunesta may allow it to

process without a prior authorization.

Please see specific STEP criteria located

at:



chloral hydrate

flurazepam (Dalmane)

temazepam 15mg, 30mg (Restoril)

triazolam (Halcion)

zaleplon (Sonata)

zolpidem (Ambien)

estazolam (ProSom)

temazepam 7.5mg, 22.5mg (Restoril)

zolpidem ER (Ambien CR)

Doral

Edluar

Intermezzo

Lunesta*

Rozerem

Silenor

Somnote

Zolpimist













Stimulants and Related Agents (Tx for Attention Deficit Hyperact (ADHD)/Narcolepsy; Adrenergics, Aromatic, Non-Catecholamine)

** For recipients 6–17 years old, Kapvay

and Intuniv is part of the mental health

formulary and billed fee-for-service. For

individuals not in this age range, Intuniv

and Kapvay continue to be part of the

MCO pharmacy benefit.

*** To view criteria for Strattera, please

refer to



1st Tier

amphetamine salt combo (Adderall)

dextroamphetamine tablets

methylphenidate tablets (Ritalin)

methylphenidate ER tablets (Ritalin SR)

methylphenidate CR tablets (Concerta)

Adderall XR (Brand only)

Daytrana

Dexedrine ER (Brand Only)

Focalin (Brand Only)

Focalin XR (Brand Only)

Intuniv**

Metadate CD (Brand Only)

Methylin liquid (Brand Only)

Quillivant XR

Ritalin LA (Brand Only)

Vyvanse

2nd Tier

Strattera *** (for ages 17 and under)

amphetamine salt combo ER (Adderall XR) (generic only)

clonidine ER (Kapvay)**

dexmethylphenidate (Focalin) (generic only)

dexmethylphenidate XR (Focalin XR) (generic only)

dextroamphetamine ER capsules (Dexedrine ER) (generic only)

dextroamphetamine solution (Procentra)

methamphetamine (Desoxyn)

methylphenidate CD capsules (Metadate CD) (generic only)

methylphenidate ER capsules (Ritalin LA) (generic only)

methylphenidate liquid (Methylin) (generic only)

modafinil (Provigil)

Methylin chewable

Nuvigil

Endocrine


Androgenic Agents Androgel

Testim

Androderm

Axiron

Fortesta

Bone Resorption Suppression and Related Agents (Bone Resorption Inhibitors, Bone Formation Stim. Agents – Parathyroid Hormone)

alendronate (Fosamax)

calcitonin salmon nasal (Miacalcin)

Fortical

alendronate solution (Fosamax Solution)

etidronate (Didronel)

ibandronate (Boniva)

Actonel

Atelvia

Binosto

Evista

Forteo

Fosamax Plus D

Prolia

Hypoglycemics, Incretin Mimetics and Enhancers

Byetta

Januvia

Janumet, Janumet XR

Juvisync

Jentadueto

Symlin

Tradjenta

Bydureon

Kazano

Kombiglyze XR

Nesina

Onglyza

Oseni

Victoza







Endocrine


Hypoglycemics, Insulins and Related Agents

Humalog

Humalog Mix

Humulin

Lantus

Levemir

Novolin

NovoLog

NovoLog Mix

Apidra

Hypoglycemics, Meglitinides (Hypoglycemics, Insulin Release Stimulant Type)

nateglinide (Starlix)

repaglinide (Prandin)

Prandimet

Hypoglycemics, TZDs (Hypoglycemics, Insulin-Response Enhancers)

pioglitazone (Actos)

pioglitazone/glimepiride (Duetact)

pioglitazone/metformin (ActoPlusMet)

ActoPlusMet XR

Avandia, Avandamet, Avandaryl

Gastrointestinal


Antiemetic/Antivertigo Agents dimenhydrinate Rx and OTC

meclizine Rx and OTC (Bonine, Antivert)

metoclopramide (Reglan)

ondansetron (Zofran, Zofran ODT)

prochlorperazine (Compazine, Compro)

promethazine (Phenergan)

Emend capsules

Marinol (Brand only)

TransDerm-Scop

dronabinol (generic only)

granisetron (Kytril)

trimethobenzamide (Tigan)

Aloxi

Anzemet

Cesamet

Diclegis

Emend IV

Metozolv ODT

Sancuso

Bile Salts ursodiol capsule (Actigall) ursodiol tablet (URSO Forte)

Chenodal

Pancreatic Enzymes pancrelipase

Creon

Zenpep

Pancreaze

Pertzye

Ultresa

Viokace

Phosphate Binders and Related Agents

Calphron OTC

calcium acetate (PhosLo)

Eliphos

Fosrenol

Magnebind 400 RX

Phoslyra

Renagel

Renvela




Gastrointestinal


Proton Pump Inhibitors (Gastric Acid Secretion Reducers)

lansoprazole Rx and OTC (Prevacid)

omeprazole (Prilosec)

pantoprazole (Protonix)

Prevacid Solutab

Protonix suspension

omeprazole/sodium bicarb (Zegerid OTC)

rabeprazole (Aciphex)

Dexilant

Nexium

Prilosec suspension

Ulcerative Colitis Agents balsalazide (Colazal)

sulfasalazine, sulfasalazine DR (Azulfidine, Azulfidine DR)

Asacol

Canasa

Delzicol

mesalamine enemas (Rowasa)

Apriso

Asacol HD

Dipentum

Giazo

Lialda

Pentasa

Rowasa, sfRowasa

Immunologics


Immunosuppressives, Oral azathioprine (Imuran)

cyclosporine modified (Gengraf, Neoral)

mycophenolate mofetil (Cellcept)

tacrolimus (Prograf)

Rapamune

Sandimmune (Brand only)

cyclosporine (generic only)

Azasan

Myfortic

Zortress

Injectables


Colony Stimulating Factors Neupogen Leukine

Neulasta

Cytokine and CAM Antagonists (Anti-Inflammatory,Pyrimidine Synthesis Inhibitor, Anti-Inflammatory, Tumor Necrosis Factor Inhibitor, Anti-Flam, Interleukin-1 Receptor Antagonist, Drugs to Tx Chronic Inflamm Disease of Colon, Antimetabolites)

Enbrel

Humira

Actemra

Cimzia

Kineret

Orencia

Remicade

Simponi

Stelara

Xeljanz

Erythropoietins (Hematinics, Other) Aranesp

Procrit

Epogen

Growth Hormones (CLINICAL PA REQUIRED)

Genotropin

Norditropin

Nutropin/Nutropin AQ

Humatrope

Omnitrope

Saizen

Serostim

Tev-Tropin




Neurologics


Alzheimer’s Agents donepezil/donepezil ODT (all strengths except 23mg) (Aricept/Aricept ODT)

rivastigmine capsules (Exelon)

Exelon patch

Namenda

donepezil 23mg (Aricept)

galantamine (Razadyne ER)

Exelon solution

Namenda XR

Anti-Parkinson’s Agents benztropine (Cogentin)

levodopa/carbidopa IR, levodopa/carbidopa ER (Sinemet, Sinemet CR)

levodopa/carbidopa/entacapone (Stalevo)

pramipexole (Mirapex)

ropinirole (Requip)

selegiline tablets (Eldepryl)

trihexyphenidyl (Artane)

bromocriptine (Parlodel)

entacapone (Comtan)

levodopa/carbidopa ODT (Parcopa)

ropinirole ER (Requip XL)

selegiline capsules (Eldepryl)

Azilect

Mirapex ER

Neupro

Tasmar

Zelapar

Multiple Sclerosis Agents (Agents to Treat Multiple Sclerosis)

Avonex

Betaseron

Copaxone

Rebif

Ampyra

Aubagio

Extavia

Gilenya

Tecfidera

Ophthalmic


Ophthalmics, Allergic Conjunctivitis (Eye Antiinflammatory Agents, Eye Antihistamines, Ophthalmic Mast Cell Stabilizers)

cromolyn (Crolom)

ketotifen OTC (Zaditor OTC)

Alrex

Pataday

azelastine (Optivar)

epinastine (Elestat)

Alocril

Alomide

Bepreve

Emadine

Lastacaft

Patanol

Ophthalmics, Antibiotics bacitracin/polymixin

ciprofloxacin solution (Ciloxan)

erythromycin

gentamicin drops (Garamycin)

neomycin/polymixin/gramicidin (Neosporin)

ofloxacin (Ocuflox)

polymyxin/trimethoprim (Polytrim)

sulfacetamide solution (Bleph-10)

tobramycin (Tobrex Drops)

triple antibiotic

Ciloxan Ointment

Moxeza

bacitracin

gatifloxacin (Zymaxid)

levofloxacin (Quixin)

sulfacetamide ointment

AzaSite

Besivance

Natacyn




Ophthalmic


Tobrex Ointment

Vigamox

Ophthalmics, Antibiotic/Steroid Combinations

neomycin/bacitracin/polymyxin/HC

neomycin/poly/dexamethasone (Maxitrol)

sulfacetamide/prednisolone

Blephamide

Pred-G

Tobradex suspension (Brand Only)

Tobradex ointment

neomycin/polymyxin/HC

tobramycin/dexamethasone suspension (generic only)

Tobradex ST

Zylet

Ophthalmics, Glaucoma Agents betaxolol

brimonidine (Alphagan P 0.1%)

carteolol (Ocupress)

dorzolamide (Trusopt)

dorzolamide/timolol (Cosopt)

latanoprost (Xalatan)

levobunolol (Betagan)

metipranolol (OptiPranolol) (Brand and generic)

pilocarpine (Pilocar)

timolol (Timoptic, Timoptic XE)

Alphagan P 0.15% (Brand only)

Azopt

Betimol

Betoptic S

Istalol

Simbrinza

Travatan Z

apraclonidine (Iopidine)

brimonidine tartrate 0.15% (Alphagan P) (generic only)

travoprost

Combigan

Cosopt PF

Lumigan

Rescula

Zioptan

Ophthalmics, Anti-Inflammatories dexamethasone (Decadron)

diclofenac (Voltaren)

fluorometholone (FML)

flurbiprofen (Ocufen)

ketorolac (Acular)

ketorolac LS (Acular LS)

prednisolone acetate (Omnipred)

prednisolone sodium (Pred Forte)

Durezol

Flarex

FML Forte

FML SOP

Lotemax Drops

Maxidex

Pred Mild

bromfenac (Xibrom)

Acuvail

Bromday

Ilevro

Lotemax ointment and gel

Nevanac

Ozurdex

Prolensa

Retisert

Triesence

Vexol




Otic


Otic Antibiotics neomycin/polymyxin/HC solution (Cortisporin)

ofloxacin otic (Floxin Otic)

Ciprodex

Cipro HC

Coly-Mycin S

Respiratory


Antihistamines, Minimally Sedating (Antihistamines)

cetirizine, cetirizine-D Rx and OTC (Zyrtec, Zyrtec D)

fexofenadine OTC (Allegra)

levocetirizine tablets (Xyzal)

loratadine, loratadine-D Rx and OTC (Claritin, Claritin D)

desloratadine (Clarinex, Clarinex-D, Clarinex RDT)

fexofenadine (Allegra)

fexofenadine D 12 hr, 24 hr (Allegra D)

levocetirizine solution (Xyzal)

Semprex-D

Beta2-Agonist Bronchodilators (Beta-Adrenergic Agents)

albuterol neb 0.083% and 5mg/ml

albuterol syrup and tablet (Proventil, Ventolin)

terbutaline (Brethine)

Foradil

ProAir HFA

Proventil HFA

albuterol ER (Vospire ER)

albuterol neb 0.63mg/3ml and 1.25mg/3ml (Accuneb)

levalbuterol (Xopenex)

metaproterenol (Alupent)

Arcapta

Brovana

Maxair

Perforomist

Serevent

Ventolin HFA

Xopenex HFA

COPD Agents ipratropium neb (Atrovent)

ipratropium neb/albuterol (DuoNeb)

Atrovent HFA

Combivent Respimat

Spiriva

Daliresp

Tudorza

Glucocorticoids, Inhaled (Beta-Adrenergics and Glucocorticoids Combination, Glucocorticoids)

* Pulmicort Respules are available

without prior authorization for children

who are 1 to 8 years of age.

Advair Diskus, Advair HFA

Asmanex

Dulera

Flovent Diskus, Flovent HFA

Pulmicort Flexhaler

Pulmicort Respules 0.25mg and 0.5mg (Brand only)*

QVAR

Symbicort

budesonide respules (generic) (All ages)

Alvesco

Pulmicort 1mg Respules




Respiratory


Intranasal Rhinitis Agents (Nasal Anti-Inflammatory Steroids)

fluticasone nasal (Flonase)

ipratropium (Atrovent Nasal)

Astelin (Brand only)

Astepro

Nasonex

Patanase

azelastine nasal (Astelin) (generic only)

flunisolide (Nasarel, Nasalide)

triamcinolone nasal (Nasacort AQ)

Beconase AQ

Dymista

Omnaris

QNasal

Rhinocort Aqua

Veramyst

Zetonna

Leukotriene Modifiers montelukast chewables and tablets (Singulair)

zafirlukast (Accolate)

montelukast granules (Singulair Granules)

Zyflo, Zyflo CR

Topical Dermatologics


Acne Agents, Topical benzoyl peroxide cleanser

benzoyl peroxide gel

clindamycin (all forms except the foam)

erythromycin

panoxyl-8 OTC

tretinoin

tretinoin micro (Retin-A Micro) (all forms except the pump)

Azelex

Desquam-X OTC

Differin (Brand only)

adapalene (generic only)

benzoyl peroxide OTC (all forms, strengths)

benzoyl peroxide kit

benzoyl peroxide towelette

bp-10-1

cerisa

clindamycin foam

clindamycin-benzoyl peroxide

erythromycin-benzoyl peroxide

sulfacetamide

sulfacetamide/sulfur

sulfacetamide/sulfur/urea

tretinoin micro pump (Retin-A Micro)

Acanya

Aczone

Akne-Mycin

Atralin

Avar (all forms, strengths)

Avita

BenzaClin

Benzamycin

Benzefoam (all forms, strengths)

Cleocin T (all forms, strengths)

Clindacin Pac Kit

Clindagel

Duac

Epiduo

Evoclin

Inova (all forms, strengths)

Klaron




Topical Dermatologics


Levoclen (all forms, strengths)

Ovace (all forms, strengths)

Pacnex (all forms, strengths)

Panoxyl-4 OTC

Plexicon

Prascion RA

SE BPO Cleanser

SSS 10-4

SSS 10-5 foam

Sumadan(all forms, strengths)

Sumaxin (all forms, strengths)

Tazorac (all forms, strengths)

Veltin

Ziana

Atopic Dermatitis Elidel Protopic

Urologic


Benign Prostatic Hyperplasia (Alpha-Adrenergic Blocking Agents)

alfuzosin (Uroxatral)

doxazosin (Cardura)

finasteride (Proscar)

tamsulosin (Flomax)

terazosin (Hytrin)

Avodart

Cardura XL

Jalyn

Rapaflo

Bladder Relaxant Preparations (Urinary Tract Antispasmodic/ Antiincontinence Agent)

oxybutynin, oxybutynin ER (Ditropan, Ditropan XL)

Toviaz

flavoxate

tolterodine (Detrol)

trospium, trospium ER (Sanctura, Sanctura XR)

Detrol LA

Enablex

Gelnique

Myrbetriq

Oxytrol

Vesicare

maryland preferred drug list 141 pdl and some... · note: brand names listed in parentheses are...

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